Figure 2.
Figure 2. Peripheral blood smears and bone marrow biopsies pre- and posttherapy of MPN-BP. (A) IDH2-mutated MPN-BP. Pretherapy with enasidenib: peripheral smear shows pancytopenia with circulating blasts. Bone marrow is markedly hypercellular and composed largely of blasts intermingled with increased atypical/dyspoietic megakaryocytes. Posttherapy (6 months of therapy with enasidenib): peripheral smear showing normal neutrophils and decline in circulating blasts. Bone marrow is hypercellular without significant increase in blasts but with increased granulopoiesis and atypical megakaryocytes, consistent with the patient’s underlying MPN. (B) TP53-mutated MPN-BP arising in a patient with PV. Pretherapy with decitabine: peripheral smear shows mild thrombocytopenia. Bone marrow is markedly hypercellular with panmyelosis and sheets of blasts. Posttherapy (2 months of therapy with decitabine): peripheral blood demonstrates leukopenia and anemia without circulating blasts. Bone marrow is hypercellular without overt increase in blasts, but with marked proliferation of erythroid precursors as well as megakaryocytes with clustering and atypia, consistent with involvement with the patient’s underlying MPN. (C) MPN-BP arising in a patient with prior postessential thrombocythemia MF. Pretherapy with decitabine: peripheral blood smear demonstrates circulating blasts (24% on differential count), red blood cell anisopoikilocytosis, marked platelet anisocytosis, and hypogranular platelets. Bone marrow biopsy specimen shows mainly fibrosis, with few hematopoietic elements distorted by the markedly increased fibrosis and few irregularly distributed mononuclear cells (blasts), which are difficult to appreciate morphologically. Postallogeneic SCT (day 180): peripheral smear demonstrates normocytic anemia, mild thrombocytopenia, and no circulating blasts. The marrow is hypercellular, with megakaryocytic and granulocytic proliferation and no increase in blasts. Fibrosis is mild at this juncture. Magnification for all images is ×500. Peripheral blood smears are stained with Giemsa; bone marrow biopsy specimens are stained with hematoxylin and eosin.

Peripheral blood smears and bone marrow biopsies pre- and posttherapy of MPN-BP. (A) IDH2-mutated MPN-BP. Pretherapy with enasidenib: peripheral smear shows pancytopenia with circulating blasts. Bone marrow is markedly hypercellular and composed largely of blasts intermingled with increased atypical/dyspoietic megakaryocytes. Posttherapy (6 months of therapy with enasidenib): peripheral smear showing normal neutrophils and decline in circulating blasts. Bone marrow is hypercellular without significant increase in blasts but with increased granulopoiesis and atypical megakaryocytes, consistent with the patient’s underlying MPN. (B) TP53-mutated MPN-BP arising in a patient with PV. Pretherapy with decitabine: peripheral smear shows mild thrombocytopenia. Bone marrow is markedly hypercellular with panmyelosis and sheets of blasts. Posttherapy (2 months of therapy with decitabine): peripheral blood demonstrates leukopenia and anemia without circulating blasts. Bone marrow is hypercellular without overt increase in blasts, but with marked proliferation of erythroid precursors as well as megakaryocytes with clustering and atypia, consistent with involvement with the patient’s underlying MPN. (C) MPN-BP arising in a patient with prior postessential thrombocythemia MF. Pretherapy with decitabine: peripheral blood smear demonstrates circulating blasts (24% on differential count), red blood cell anisopoikilocytosis, marked platelet anisocytosis, and hypogranular platelets. Bone marrow biopsy specimen shows mainly fibrosis, with few hematopoietic elements distorted by the markedly increased fibrosis and few irregularly distributed mononuclear cells (blasts), which are difficult to appreciate morphologically. Postallogeneic SCT (day 180): peripheral smear demonstrates normocytic anemia, mild thrombocytopenia, and no circulating blasts. The marrow is hypercellular, with megakaryocytic and granulocytic proliferation and no increase in blasts. Fibrosis is mild at this juncture. Magnification for all images is ×500. Peripheral blood smears are stained with Giemsa; bone marrow biopsy specimens are stained with hematoxylin and eosin.

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